Clinical Gastroenterology and Hepatology 2015;13:1560–1566

PERSPECTIVES IN CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Should the Reflex Be Reflux? Throat Symptoms and Alternative Explanations David O. Francis* and Michael F. Vaezi‡

*Vanderbilt Voice Center, Department of Otolaryngology, Bill Wilkerson Center, Center for Surgical Quality and Outcomes Research, Institute for Medicine and Public Health; ‡Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee

Although laryngopharyngeal reflux, also known as extra- asymptomatic reflux, which manifests in sundry vague esophageal reflux (EER), was codified more than 25 years upper-airway symptoms.9 Although these symptoms ago, it has not been characterized fully. There is no sensi- initially were limited to the proximate upper airway (ie, tive and specific diagnostic test, and its symptoms often pharynx and larynx), over the past 20 years, LPR has fi are nonspeci c and overlap with those of other conditions been implicated in everything from otitis media10,11 to commonly seen in primary care and specialist practices. asthma,12 with variable degrees of scientific rigor. Otolaryngologists have an important role in the evaluation — Laryngopharyngeal or, perhaps more appropriately and management of these patients they must investigate fl persistent reflux-attributed symptoms by direct visualiza- termed, extraesophageal re ux (EER), exists; however, a fi tion of the upper airway and larynx, and, in some cir- sensitive and speci cgoldstandardmethodtoidentify cumstances, the esophagus. It is of utmost importance to these patients consistently remains elusive despite expo- rule out the possibility of malignancy, which often presents nentially growing literature (Figure 1), rapid technological with symptoms similar to those of EER. Once cancer is advancements, and vast expenditure on the subject.13 Many excluded, many benign upper airway conditions also can investigators have tried to correlate specific endoscopic masquerade as, and often incorrectly are attributed to, findings and the presence of reflux with little success.14–16 EER. Although reflux is a potential etiologic factor for This limitation has been recognized by the American Col- fl upper-airway symptoms, it is important not to re exively lege of Gastroenterologists, who in their most recent GERD fl blame re ux. We discuss other etiologies that should be guidelines specifically state that GERD cannot be diagnosed considered carefully for persistent symptoms. based solely on laryngoscopy.17 Despite the lack of patho- gnomonic symptoms or signs, EER has become a primary Keywords: LPR; GERD; Treatment; Therapy. diagnosis offered by otolaryngologists, allergists, gastroen- terologists, and primary care physicians, and has resulted in many patients given a barrage of medications, undergoing astroesophageal reflux disease (GERD) affects an diagnostic tests, and even undergoing surgeries.13 Gestimated 40% of the US population.1 It therefore is no surprise that GERD medications are among the highest-selling pharmaceutical classes; totaling more than Role of the Otolaryngologist 127 million US prescriptions and $9.5 billion for proton 2 pump inhibitor (PPI) sales alone in 2012. Increased atten- EER has been associated with many symptoms tion to GERD has shifted focus to whether it affects other including hoarseness, cough, dyspnea, globus, post-nasal physiologic processes beyond the esophagus into the up- drainage, and dysphagia. These otolaryngologic symptoms per and lower respiratory tracts. Anecdotes dating back are some of the most common seen in the primary care to the 1960s hypothesized a connection between reflux 18 3,4 5 6,7 setting, where most are treated appropriately. However, and hoarseness, cancer, and upper-airway pathology. when refractory, voice, swallowing, and breathing com- These propositions were based largely on the proximity of plaints often are referred to specialists for further the upper-esophageal sphincter and laryngeal inlet and the symptom-based assessment. Thus, pulmonologists, inherent potential for extraesophageal refluxate spillage onto laryngeal and hypopharyngeal mucosa. In 1991, Kouf- 8 man operationalized and codified laryngopharyngeal Abbreviations used in this paper: EER, extraesophageal reflux; GERD, fl fi gastroesophageal reflux disease; LPR, laryngopharyngeal reflux; MTD, re ux (LPR), nding that it did have a greater affect on muscle tension dysphonia; PPI, proton pump inhibitor. laryngeal function than previously considered. Further- Most current article more, a distinction was made and perpetuated that LPR pa- © 2015 by the AGA Institute tients do not necessarily have classic GERD symptoms (eg, 1542-3565/$36.00 heartburn, regurgitation); rather, a large proportion have http://dx.doi.org/10.1016/j.cgh.2014.08.044 September 2015 Throat Symptom Explanations 1561

Figure 1. Publications on Laryngopharyngeal Reflux or Extraesophageal Reflux Over Time (Source: Web of Science)

Table 1. Alternative Laryngopharyngeal Pathologies With Symptoms Overlapping With Those Attributed to Extraesophageal Reflux and Their Laryngoscopic Findings

Pathology EER-associated symptoms Typical laryngoscopy findings

Muscle tension dysphonia Hoarseness, globus, throat pain, dysphagia No vocal fold lesions Superglottic hyperfunction Vocal fold paralysis/paresis Hoarseness, cough, dysphagia, dyspnea Immobile or hypomobile vocal fold Globus Glottic insufficiency Ipsilateral vocal fold atrophy Æ bowing Supraglottic hyperfunctiona Presbylaryngis Hoarseness, cough, globus Bilateral vocal fold bowing Glottic insufficiency Supraglottic hyperfunctiona Irritable larynx syndrome Cough, globus, hoarseness Normal laryngoscopy (typical) Vocal fold erythema/edema Cancer Throat pain, hoarseness, cough, dysphagia Mass in pharynx or larynx Æ superficial ulceration Dyspnea, globus, ear pain Vocal fold leukoplakia Vocal fold hypomobility (if joint involved) Recurrent respiratory Hoarseness, cough, dyspnea, globus Sessile or pedunculated fungiform mass in larynx/trachea papillomatosis Red stippling or vascular stalks within lesion Laryngotracheal stenosis Hoarseness, dyspnea Narrowing at supraglottis, glottis, subglottis, or trachea Scarring at site of stenosis Æ erythema Phonotraumatic lesion Hoarseness Nodule, polyp, cyst, fibrous mass on vibratory edge Glottic insufficiency Supraglottic hyperfunctiona Vocal fold hemorrhage Hoarseness Submucosal hemorrhage Ipsilateral vocal fold edema/erythema Polypoid corditis Hoarseness, cough, globus, Æ dyspnea Polypoid changes of entire vocal fold epithelium Hyperdynamic mucosa Vocal fold scarring Hoarseness Vocal fold sulcus Supraglottic hyperfunction Vocal process granuloma Throat pain (often ipsilateral), hoarseness Lesion or ulceration at arytenoid vocal process Cough, globus Glottic insufficiency (depending on size) Supraglottic hyperfunctiona Laryngeal candidiasis Throat pain, hoarseness, cough, dysphagia White speckling of fungus in pharynx and larynx Globus Laryngeal erythema Æ ulcerations Zenker’s diverticulum Regurgitation, hoarseness, dysphagia Normal laryngoscopy (typical) Globus Food debris in left pyriform sinus Paradoxic vocal fold motion Dyspnea Normal laryngoscopy at rest Laryngospasm with triggers (eg, scents, exercise)

aCompensatory muscle tension dysphonia. 1562 Francis and Vaezi Clinical Gastroenterology and Hepatology Vol. 13, No. 9 allergists, gastroenterologists, and otolaryngologists var- Gastroesophageal Reflux Disease iably are consulted. Of these subspecialties, otolaryngolo- gists have a unique role and advantage because of their In all circumstances, the presence or absence of classic ability to routinely perform awake, nonsedated, rigid and/ gastroesophageal reflux symptoms (ie, heartburn, regurgi- or flexible endoscopic assessments of the upper airway tation) are reviewed. Patients presenting to the otolaryn- from the nose to the trachea and, in some cases, the gologist may have concomitant GERD symptoms with their esophagus. upper-airway symptoms of hoarseness, cough, globus, and others. If so, this should raise suspicion that EER may be a Malignancy contributor to their upper-airway complaints. These pa- tients may require antireflux treatment and/or referral to a gastroenterologist for appropriate testing.24 However, The first step in any evaluation is to perform a many, or arguably most, patients with EER will have silent focused history and physical examination. The biggest reflux devoid of classic GERD symptoms,9 thereby requiring concern when evaluating often nonspecific upper-airway more thoughtful and subtle questioning, examination, and, concerns is to rule out malignancy. Laryngeal and when necessary, testing. In every patient it is important to pharyngeal malignancies can be insidious, presenting parse out the onset, duration, relieving factors, and exac- only with vague complaints such as sore throat, hoarse- erbating factors for their chief complaint. For example, ness, globus, and even referred ear pain. Overlap be- coughing or laryngospasm that wakes a patient from sleep tween symptoms of EER and early laryngeal cancer has been associated with nocturnal GERD, but also can be a (Table 1) have led many to suggest EER as a cancer risk 25–27 – symptom of obstructive sleep apnea. factor.19 22 However, establishing temporality to avoid Moreover, any medical interventions directed at allevi- reverse causality (ie, effect preceding purported cause) ating symptoms should be discussed. A large portion of must be considered carefully to prevent perpetuation of patients presenting to the otolaryngologist for presumed a potentially false association.23 Further study is EER have been started on empiric PPI therapy.28 If so, in- important to characterize this relationship. quiry into the duration of treatment, dose, dosing schedule It is necessary to perform a careful history considering (eg, once or twice daily), and timing (eg, before meals) is known risk factors, which includes inquiry into smoking, compulsory. It is particularly important to ask about alcohol use, occupational exposures, and other behavioral compliance with antireflux medication. Lack of compliance and lifestyle choices. Furthermore, any warning symptoms can result in false-negative treatment failures and also, in of unexplained weight loss, night sweats, and others should the case of PPIs, cause breakthrough reflux events.29 be gleaned. All physicians must be aware that persistent Breakthrough or rebound events can confound patients’ and refractory symptoms often casually attributed to EER perception of the identity and severity of their underlying can, in rare circumstances, be harbingers for malignancy. condition. Perhaps most critical, however, is to determine Concern for malignancy is heightened further and earlier whether medication has reduced their symptoms. referral to otolaryngology is indicated in patients with Nonetheless, symptom response is complicated persistent EER-associated symptoms and known risk fac- because the act of giving a diagnosis and providing tors for head and neck cancer (eg, tobacco, alcohol use). medical treatment can engender a placebo effect and/or Referral to otolaryngology allows for a focused examina- may influence patients to alter their diet, and improve tion of the nasal vault, oral cavity, nasopharynx, their vocal hygiene (eg, hydration). Thus, accurately oropharynx, and should include noninvasive visualization measuring treatment response is difficult. Caution also of the pharynx and larynx via fiberoptic laryngoscopy and/ must be exercised to establish a cause and effect be- or stroboscopy. If concern for malignancy is confirmed, tween reflux and presenting EER-attributable symptoms. then further work-up and biopsy are indicated. Nearly all people experience postprandial physiologic reflux and this must be differentiated from pathologic Benign Conditions reflux, which by its nature has symptomatic ramifica- tions. Thus, normal patients theoretically will test posi- Most upper-airway complaints such as hoarseness, tive for reflux if they are tested frequently enough or cough, and globus have nonmalignant etiologies. Once with tests that have very high sensitivities (and thus low malignancy is excluded by careful examination, endo- specificity). Moreover, it is important that alternative scopic visualization and, potentially, ancillary testing explanations be considered if increasingly more sensitive (eg, computed tomography); it is necessary to investigate tests have to be used to prove causation between reflux alternative explanations. A comprehensive discussion is and vague upper-aerodigestive symptoms. beyond the scope of this commentary; however, an abbreviated list of potential pathologies with symptoms that overlap with EER is provided in Table 1. A brief Cough and Globus review of standard work-up and management consider- ations for some of the more common EER-associated Cough is one of the most common conditions seen conditions is discussed in the following sections. worldwide by primary care physicians and exists at a September 2015 Throat Symptom Explanations 1563 watershed of several specialties, which is testament to secretions in the upper airway and worsen cough, throat the complexity of its mechanism. Afferent triggers are irritation, and globus. Therefore, hydration and avoid- mediated by chemoreceptors, and nocireceptors within ance of excessive drying medications, although seem- the respiratory system (ie, nose to alveoli) provide ingly simplistic, can reverse some symptoms often feedback to the cough center within the medulla, which, attributable to reflux (eg, hoarseness, globus). Such in turn, activates an efferent cascade and reflex that in- behavioral throat hygiene education and interventions volves instantaneous vocal fold closure. Tight and com- should be considered as first-line therapy before enter- plete laryngeal closure permits creation of a transglottic taining a diagnosis of EER. pressure gradient that translates into aggressive expul- Another important component in the assessment of sion of noxious material from the respiratory tract when chronic cough is to determine the triggers. Classic trig- the subglottic pressure threshold is exceeded. Illustrating gers for cough are irritants/allergies, postnasal drainage the vocal folds’ importance is the recognition that pa- (as discussed), infection, asthma, and reactive airway tients with vocal fold paresis or paralysis who are unable disease. There is also mounting evidence that reflux may to achieve vocal fold closure have frequent complaints of play a role and be a prevalent cause of chronic cough.34 inefficient cough, inability to clear pharyngeal secretions, Determining this relationship is complicated and often is and globus sensation.30,31 Thus, the vocal folds play a presumed based on response to empiric treatment with central effector role in cough. This often is overlooked in PPI therapy. If the cough subsides after therapy then the initial work-up, which typically focuses on nasal or reflux is the assumed culprit. Other patients with chronic pulmonary-related cough etiologies (eg, rhinitis, infec- cough undergo esophagoduodenoscopy or transnasal tion, asthma, allergies). Moreover, there is a misconcep- esophagoscopy with or without pH and impedance tion in the public and among some physicians that testing. Abnormal testing in the presence of chronic bronchitis and cough are synonymous. Assessing cough strengthens the potential association. For example, whether someone truly has swelling of the bronchi is a recent study showed that those patients with rare. Instead, bronchitis in this setting more appropri- concomitant heartburn and/or regurgitation and esoph- ately may describe laryngitis that occurs as a result of ageal pH less than 4 more than 12% of the time over a repeated vocal fold trauma from coughing. It follows that 24-hour period were significantly more likely to have patients who have chronic cough often have concomitant resolution of their EER symptoms after Nissen hoarseness, globus, and pharyngitis from irritation. fundoplication.35 Chronic cough frequently is accompanied by globus However, voice behavior is a less-discussed and sensation and or postnasal drainage symptoms. Obtain- perhaps more common trigger in this population.36 ing a careful history of the present illness in addition to Phonation requires vocal fold vibration, which causes reviewing previous and current medical treatments is vocal fold perturbation. If the larynx has been sensitized critical because many are being treated aggressively with by chronic cough then this can decrease the cough various regimens that can, in certain circumstances, be threshold. Irritable larynx syndrome is a term used to counterproductive. Rarely on flexible laryngoscopy do describe chronic cough and throat irritation that results these symptoms correlate with an actual foreign body, from repeated vocal fold trauma and manifests in the throat lesion, or excessive running postnasal drainage; form of a sensory neuropathy.37,38 Highlighting the rather, what is seen on examination is thickening of trauma’s intensity is the recognition that the sound of upper airway secretions (ie, mucus and saliva). The hu- cough derives from violent vocal fold adductory contact man body makes between 0.75 and 1.5 L of secretions and release. If someone has chronic cough, they are from the upper airway daily,32 which is all sluiced into necessarily causing repeated trauma to their vocal folds, the esophagus. Thus, postnasal drainage is not a syn- which causes irritation, swelling, and a foreign body drome,33 but rather a normal physiologic process. sensation. The body’sreflex to such irritation/foreign Experience is that patients describing postnasal drainage body sensation at the glottis is to throat clear or cough, symptoms often have significantly thickened secretions which perpetuates the process in a positive feedback (ie, decreased water leading to increased protein con- loop. Thus, cough begets cough. Beyond improving vocal centration), which the body recognizes as abnormal, thus hygiene as described earlier, the goal of treatment is to manifesting in throat clearing and cough. desensitize the laryngeal mechanism. Often, this requires Patients with globus or postnasal drainage and cough trying to change a person’s reaction to this sensation. For traditionally are thought to have allergies and are placed example, rather than quenching the urge by coughing, on antihistamines, decongestants, and often self- instead the sensation can be used as a cue to take a hard medicate with metholated cough drops. All of these swallow of water, which, over time, can help to break this interventions act to increase the viscosity of these cycle. secretions and can, in some circumstances, exacerbate Several other medical and behavioral treatment op- symptoms. Furthermore, it is critical that patient history tions have been proposed.39 In particular, this condition should focus on other drying medications that they may is one that can benefit from speech language pathology be taking because these can exacerbate the situation intervention. There is a growing body of literature further. Caffeine also can act as a diuretic and can thicken regarding therapy techniques for cough that specially 1564 Francis and Vaezi Clinical Gastroenterology and Hepatology Vol. 13, No. 9 trained speech language pathologists can use to help this presumed cause. There is a tendency to treat all vocal patient population.40,41 Finally, those patients with process granulomas as if they were related to reflux, but a chronic cough secondary to irritable larynx syndrome or more pragmatic approach is to carefully consider neuropathic cough refractory to vocal hygiene and other possible etiologies. For example, prognosis for desensitization therapy may require pharmacologic in- spontaneous recovery is best when symptoms start in terventions. In these situations, appropriately dosed close proximity to intubation-related trauma.53 In this medications used for peripheral sensory neuropathies same study, Wang et al53 found that 82% of 53 patients (eg, gabapentin, tricyclic antidepressants) can be help- with granulomas achieved spontaneous remission be- ful.42 For example, these patients are often treated with tween 13 and 70 weeks (mean, 30.6 wk) without any an escalating dose of gabapentin, amitriptyline, or bac- treatment. Determining whether the relationship between lofen. There is growing data that these may be helpful in reflux and granulomas represent an association, causa- a select group of patients.42 tion, or co-factor has proven difficult because of their relative rarity and an inability to perform rigorous large- scale epidemiologic or interventional studies. Hoarseness In situations in which no identifiable mass lesion or neurologic deficit is present, there is a reflex to attribute Extraesophageal reflux also commonly is implicated in hoarseness to reflux. Many argue that it is easier and unexplained hoarseness. Although there is evidence to potentially more cost effective to treat patients empiri- suggest that it does and can play a role, there are many cally with a PPI than to spend additional time and effort other possible explanations for this symptom and, there- investigating other explanations. However, all nonor- fore, a careful otolaryngologic history and examination ganic persistent dysphonia is not reflux. Large epidemi- can be enlightening. History should include onset (eg, ologic studies have found that the most common upper-respiratory infection, surgery, intubation, allergy), diagnoses made in dysphonic patients are “non-specific duration, relieving/exacerbating factors, presence or dysphonia” and “acute laryngitis.”54 The nonspecific recent history of cough, and consistency of hoarseness dysphonia International Classification of Disease, Ninth symptoms (eg, constant, variable, fatiguing). It also is Revision, Clinical Modification code is the code typically critical to determine whether any inter- used by otolaryngologists for muscle tension dysphonia ventions—medical, surgical, or behavioral—have been (MTD), a muscular dyscoordination and inefficiency in exercised to treat the condition. An examination of the the voicing mechanism or for other functional dysphonia larynx with laryngoscopy is standard of care for a patient conditions. Based on experience, MTD is one of the most with persistent dysphonia to rule out malignancy, mass common diagnoses made in patients presenting with lesions, or neurologic deficits (Table 1). Most isolated chronic dysphonia. Moreover, MTD can occur as a pri- vocal fold lesions are considered phonotraumatic in origin mary diagnosis, but it also exists as a compensatory or secondary to voice overuse, misuse, or abuse. Their secondary phenomenon in patients with laryngeal le- presence can result in glottic insufficiency and mediate an sions, neurologic deficits, or inflammation (Table 1). inefficient cough, and thereby interfere with clearance of Differentiating the cause of nonorganic dysphonia can be secretions from the laryngeal inlet. It is not uncommon for complex and often requires the expertise of specialists in patients with glottic insufficiency to have symptoms that voice (ie, laryngologists, speech language pathologists) overlap with those attributed to EER. In fact, studies have who have expertise in evaluating the voicing mechanism shown that cough can be eliminated and the reflux perceptually and laryngoscopically. symptom index43 normalized when patients’ glottic Studies have highlighted that the symptoms of MTD insufficiency was corrected.31,44 This highlights the rela- and LPR/EER significantly overlap,28,55 thus further tive insensitivity of using symptoms in general, and this muddying the distinction. This conundrum breeds measure specifically, to identify those with LPR/EER. different approaches. Some clinicians empirically treat Instead, these symptoms seem to be a more generalized with PPIs, with the expectation that if no improvement is measure of vague and nonspecific throat symptoms. achieved then perhaps the diagnosis is MTD instead. One lesion identifiable on laryngeal examination that Others approach this problem from the opposite direc- has been linked to reflux is vocal process ulceration or tion, opting for voice therapy as the primary modality. granuloma,45 which tend to present with asymmetric Effective treatment with this modality requires the discomfort in the throat with or without hoarseness and treating speech language pathologist to have experience, globus.46 Several etiologies have been proposed including knowledge, and the skill set to treat voice disorders. The trauma from intubation or instrumentation,47,48 phono- Cochrane Collaboration has found that voice therapy is trauma,48,49 glottic insufficiency,50 and EER.45 Granu- an effective treatment for muscle tension or functional lomas typically occur secondary to mucosal disruption dysphonia,56 and it is appropriately recognized as the over the vocal process of the arytenoid cartilage with standard of care for this disorder. Reinforcing the over- subsequent development of perichondritis.51,52 These le- lap between MTD and LPR is a study by Park et al,57 who sions can be difficult to manage depending on their eti- randomized patients with presumed LPR to treatment ology and, therefore, treatment is directed based on the with either PPI alone or PPI combined with voice September 2015 Throat Symptom Explanations 1565 therapy. Interestingly, patients randomized to combina- 5. Jacobs A. Post-cricoid carcinoma: regional incidence in En- tion treatment had significantly greater improvement in gland and Wales. BMJ 1963;2:1373–1375. subjective and perceptual voice measures compared with 6. Delahunty JE, Cherry J. Experimentally produced vocal cord those receiving PPI alone. This finding has been inter- granulomas. Laryngoscope 1968;78:1941–1947. preted variably, but does imply that voice therapy is an 7. Cherry J, Margulies SI. Contact ulcer of the larynx. Laryngo- – effective treatment for LPR, which physiologically is scope 1968;78:1937 1940. difficult to reconcile. Instead, their results seem to pro- 8. Koufman JA. The otolaryngologic manifestations of gastro- fl vide evidence that some proportion of their patients had esophageal re ux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an MTD in addition to, or in lieu of, LPR. In summary, experimental investigation of the role of acid and pepsin in the symptoms attributed to LPR overlap substantially with development of laryngeal injury. Laryngoscope 1991;101:1–78. MTD, making some question whether a trend toward 9. Koufman JA. Laryngopharyngeal reflux is different from misdiagnosis of MTD has increased the relative preva- classic gastroesophageal reflux disease. Ear Nose Throat J 2002; lence of LPR. 81:7–9. 10. Luo HN, Yang QM, Sheng Y, et al. Role of pepsin and pepsin- Conclusions ogen: linking laryngopharyngeal reflux with otitis media with effusion in children. Laryngoscope 2014;124:E294–E300. 11. He Z, O’Reilly RC, Mehta D. Gastric pepsin in middle ear fluid of fi 8 Despite its codi cation more than 25 years ago, lar- children with otitis media: clinical implications. Curr Allergy yngopharyngeal reflux or extraesophageal reflux is a Asthma Rep 2008;8:513–518. condition yet to be fully characterized. In a recent edito- 12. Saritas Yuksel E, Vaezi MF. Extraesophageal manifestations of rial, EER management has been described as “furor gastroesophageal reflux disease: cough, asthma, laryngitis, medicus”58: the unbridled frenzy of doctors to do some- chest pain. Swiss Med Wkly 2012;142:w13544. thing, especially when the clinical situation is confusing. In 13. Francis DO, Rymer JA, Slaughter JC, et al. High economic general, this situation is promulgated by the uncertainty burden of caring for patients with suspected extraesophageal of the doctor, and the insistence of the patient to get reflux. Am J Gastroenterol 2013;108:905–911. something done. It behooves the broad medical commu- 14. Milstein CF, Charbel S, Hicks DM, et al. Prevalence of laryngeal nity that treats these patients to do a better job at defining, irritation signs associated with reflux in asymptomatic volun- fl diagnosing, and treating this disorder. The otolaryngolo- teers: impact of endoscopic technique (rigid vs. exible laryn- – gist plays an important role because most EER-associated goscope). Laryngoscope 2005;115:2256 2261. symptoms fall within our purview. Many upper-airway 15. Qadeer MA, Swoger J, Milstein C, et al. Correlation between symptoms and laryngeal signs in laryngopharyngeal reflux. conditions can masquerade as, and easily incorrectly be Laryngoscope 2005;115:1947–1952. attributed to, EER. It is easy to reflexively blame reflux. 16. Powell J, Cocks HC. Mucosal changes in laryngopharyngeal However, a more thoughtful approach that heeds my reflux–prevalence, sensitivity, specificity and assessment. ’ “ ’ medical school neurology professor s advice, don t just Laryngoscope 2013;123:985–991. ” do something, stand there, is advocated when consid- 17. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and ering the differential diagnosis. In the context of EER, management of gastroesophageal reflux disease. 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44. Patel AK, Mildenhall NR, Kim W, et al. Symptom overlap Conflicts of interest between laryngopharyngeal reflux and glottic insufficiency in The authors disclose no conflicts.